The natural history of growth-friendly graduates treated with growing instrumentation but no final fusion is unknown. Two previous reports exist with one analyzing 30 growin g rod patients with no definitive fusion and another including 10 patients with growing rod removal, but no comprehensive data exist in the literature. A multi-center database was queried for patients treated with TGR or VEPTR and at least 2 years of follow-up from their index procedure. Patients met inclusion criteria if they had not undergone a final fusion procedure but had completed planned interventions for early onset scoliosis and had sufficient follow-up. Kaplan–Meier analysis was performed to model rates of UPROR and complications in patients with retained and removed implants over time. Of 233 included patients, definitive treatment was implant maintenance in 203 (87

BACKGROUND:Treatment options for early-onset scoliosis (EOS) are confounded by the risks associated with intervention at a younger age. Spinal instrumentation must be considered carefully due to potentially adverse effects to the spine, chest wall, and lungs. Posterior spinal fusion before subsequent growth can also lead to the crankshaft phenomenon. With the recent increasing interest in delaying spinal fusion, we aim to determine trends in patient age selection at a single definitive (termed "one and done") fusion for EOS. METHODS:We identified 791 patients from 2005 to 2022 who met the inclusion criteria (age 5 y or younger, single definitive fusion, and complete data). Patients who underwent a hemivertebrae resection with limited fusion were not included. Multiple linear regression was performed with date of fusion as the independent variable and age at definitive fusion as the dependent variable. Our regression included race and sex to control for their effects as confounders. We repeated this analysis with groups separated by scoliosis etiology and sex. Coefficients with P <0.05 were considered significant. RESULTS:In the entire cohort, there was no significant change in the age at definitive fusion between 2005 and 2022 (coefficient=0.042, P =0.099). The mean age at fusion was 12.1 years. Of these, 167 (21.1%) cases had congenital scoliosis, 277 (35.0%) had idiopathic scoliosis, 191 (24.1%) had neuromuscular scoliosis, and 156 (19.7%) had syndromic scoliosis. Patients with idiopathic (-0.002, P =0.962), syndromic (-0.027, P =0.671), and neuromuscular (-0.005, P =0.924) EOS showed no significant change in the age at fusion. However, children with congenital EOS (0.171, P =0.006) and females (0.082, P =0.003) demonstrated a significant increase. On the basis of our regression models, the predicted age at definitive fusion increased from 10.6 years to 12.3 years in those with congenital EOS and from 11.4 to 12.1 years in females. CONCLUSIONS:Over a 17-year study period, females and congenital EOS patients demonstrated significant increases in age at the time of definite fusion. There was no significant change for children with neuromuscular, idiopathic, or syndromic EOS over the same time frame. Further study is necessary to determine the nature of these disparities.

Background: A spinal cord morphology classification has linked intraoperative neuromonitoring (IONM) alerts in adults undergoing spine deformity correction with spinal cord type. The purpose of this study was to apply the same classification to Adolescent Idiopathic Scoliosis (AIS) patients undergoing spinal fusion and investigate the association of alerts to cord type. Methods: AIS patients with pre-operative MRIs of the neural axis from 2019-2022 who underwent spinal fusion were included. T2-weighted axial MRI images at the deformity’s apex were used to classify spinal cord morphology into 3 types as described by Sielatycki et al. Cord type was associated with preoperative demographic and radiographic findings and the occurrence of IONM alerts during surgery. Results: Eighty-three patients qualified for inclusion. There were 32 (39%) Type 1, 45 (54%) Type 2, and 6 (7%) Type 3 cords. Patients with Type 3 cords demonstrated a significantly larger mean Cobb angle (P=0.004), coronal DAR (P=0.002), and larger preoperative kyphosis (P=0.033). There were 14/83 patients (17%) with IONM alerts: 3/32 (9%) in Type 1, 7/45 (16%) in Type 2, and 4/6 (67%) in Type 3. The odds of an IONM alert were 19.33x greater with a Type 3 cord versus a Type 1 cord (P=0.003). Males were at greater risk of IOMN alerts (P=0.042). Conclusions: In a cohort of exclusively AIS patients, a Type 2 cord was the most common (54%). Type 3 cords demonstrated significantly larger coronal and sagittal plane radiographic deformities and demonstrated a 19.33x higher odds ratio of an IONM alert than Type 1. Level of Evidence: Diagnostic Level III

OBJECTIVES:State laws dictate firework access in the USA, and the association between state laws and paediatric firework injuries has not been investigated. We hypothesise that states with fewer firework restrictions will have a higher incidence of paediatric firework injuries. METHODS:A retrospective review (2012-2020) of paediatric patients who sustained a fireworks-related injury was conducted using the Pediatric Health Information System. Inclusion criteria were age less than 18 years and International Classification of Diseases code for fireworks-related injury. States were classified as 'unrestrictive' or 'restrictive' based on permitted fireworks. Case number, demographics and injury severity were evaluated. A negative binomial regression was used to evaluate independent variables predictive of firework injuries, with the dependent variable being the number of injuries. Independent variables that were predictive of number of injuries were subsequently evaluated with a Mann-Whitney test to determine the significance of the differences between 'unrestrictive' and 'restrictive' states. RESULTS:During the study period, 2299 fireworks-related injuries were reported. Mean age was 9.2±4.8 years (range 0-17). Most injuries, based on raw numbers, were in 'unrestrictive' states (72.6%). When normalised measures were used for comparison, based on paediatric state population, there was a statistically significant difference with a higher percentage of injuries in unrestricted states (p=0.002). The mean number of cases per million pediatric-aged individuals was higher in the 'unrestrictive' states versus the 'restrictive' states (p=0.003). CONCLUSIONS:States with fewer firework restrictions had a higher incidence of fireworks-related injuries in children. Restricting fireworks may protect children from fireworks-related injuries.

Objective(s): Spinal Fusion (SF) for Adolescent Idiopathic Scoliosis (AIS) is an effective procedure for curve correction and arthrodesis. Regular patient follow-up is beneficial for clinical and radiographic surveillance and patient outcomes. This study aimed to investigate risk factors for decreased patient follow-up after SF for AIS. Methods: AIS patients who underwent SF at a single tertiary medical center from 2017 to 2022 and were eligible for 1, 2 or 5 years follow up were retrospectively reviewed. Results: During the 6-year study period, 215 SF were recorded, with a median age at SF of 14 years (interquartile range [IQR 3]) and 166 females (77%). Follow up completion to eligibility status for each of the three time points was as follows: 1 year 157/215 (73%), 2 years 74/154 (48%) and 5 years 10/37 (27%). Univariate analysis demonstrated that Black patients (p=0.007) and those with public insurance (p<0.001) were significantly less likely to compete 1-year follow-up. At 2-year follow up, significant differences were only found for Black patients (p=0.042). Of the patients who qualified for 2 year follow up, median round trip driving distance was 66.64 miles (IQR 165.05); although increased driving distance did not affect completion of 2 year follow up (p=0.586). Conclusion: In a cohort of 215 SF patients with AIS, follow up completion dropped off from 1 year (73%) to 2 year (48%) to 5 year (27%). Black patients and those with public insurance were significantly less likely to complete 1-year follow-up.

STUDY DESIGN:Modified Delphi consensus study. OBJECTIVE:To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA:Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the perioperative period are not available. METHODS:A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuroelectrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on a literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculoperitoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologist participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of 3 survey rounds and 1 virtual meeting were conducted. RESULTS:Consensus was reached on 39 total postulates across 6 IPD types. Postulates addressed general spine surgery considerations, the use of intraoperative monitoring and cautery, the use of magnetically controlled growing rods (MCGRs), and the use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4% to 100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION:Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. The final postulates from this study can inform the perioperative and postoperative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE:V-Expert opinion.

OBJECTIVE Firearm injuries are the leading cause of death for children in the United States. Child access prevention (CAP) laws have been passed in some states. This study examines characteristics of children with firearm injuries in states with different types of CAP laws. METHODS The Pediatric Health Information System database was reviewed to identify all pediatric firearm injury patients between 2016 and 2021. Hospital data were categorized based on state laws as (1) no CAP laws (2) some CAP laws or (3) strict CAP laws. CAP laws that specifically outlined criminal liability for the negligent storage of firearms were considered a strict restriction, whereas any other form of CAP law was considered some restriction. χ-squared and independent-samples median testing were performed to compare restriction levels. RESULTS Between 2016 and 2021, 12 853 firearm injuries were recorded in the Pediatric Health Information System database. In states with strict CAP laws, patients were significantly older (P < .001) and had a significantly higher household income (P < .001) compared with patients in states with no CAP laws. Gender, race, and the number of firearm injuries differed between the 3 restriction levels. There were less firearm injuries observed than expected in cities with strict CAP laws. CONCLUSIONS CAP laws are associated with a higher age and household income of pediatric firearm injury patients. Given the disparities seen between cities, a federal CAP law may best protect children nationwide.

Study Design: Retrospective review Purpose: To quantify trends in published research in 8 major orthopaedic and spine journals related to Early Onset Scoliosis (EOS) from 2005-2020. We also investigated publication trends in specific subtopics within EOS research. Methods: The electronic archives of 8 journals (Spine, European Spine Journal, Journal of Children’s Orthopaedics, Spine Deformity, Journal of Pediatric Orthopaedics, Journal of Pediatric Orthopaedics B, The Journal of Bone and Joint Surgery-American Volume and The Bone and Joint Journal) were queried for articles published from 2005-2020 containing search terms particular to the following subtopics of EOS research: congenital scoliosis, infantile scoliosis, thoracic insufficiency syndrome, scoliosis casting, Traditional Growing Rod, Vertical Expandable Prosthetic Titanium Rib, Magnetically Controlled Growing Rod and EOS in general. Results were screened to exclude editorials, conference papers and corrections. Included EOS articles were aggregated and analyzed with respect to journal, year of publication and subtopic. Results: From 2005-2020, a total of 32,000 publications were identified, of which 1,818 (5.7%) were qualified as EOS articles by the presence of at least one search term. The annual number of EOS articles increased from 60 in 2005 to 157 in 2020 and the annual ratio of EOS articles to total publications increased from 4.1% to 7.9%. Congenital spine-related terms matched to the greatest number of articles, while implant-related terms collectively experienced the greatest percentage increase in matching articles per year. Conclusion: The number of EOS articles published in 8 major orthopaedic and spine journals increased in both absolute and relative terms from 2005-2020. Implant-related subtopics saw the greatest increase.

Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost. Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or 0.625/mile and208.2/day off work to calculate a relative financial burden. A total of 300 patients were analyzed (55

Background: Surgical treatment of Early Onset Scoliosis (EOS) involves operations with repetitive maneuvers that may put a surgeon at risk for a work-related Musculoskeletal Disorder (MSD). The purpose of this study was to evaluate the prevalence of MSDs that surgeons self-attributed to EOS operations. Methods: Surgeons in an international study group were invited to participate in a 41-question survey and data was analyzed from surgeons with 5 or more years of experience post training. This included demographics, occurrence of an MSD directly attributed to repetitive EOS surgery, MSD anatomic location and treatment type. Results: A total of 60 respondents qualified. Most respondents were male (51/60, 85%), with a mean age of 53 (range 36-78) and a mean of 20 years in practice (range 5-47). They reported a mean of 102 spine surgeries per year (range 12-300). A total of 117 MSDs were reported; the most common being cervical spine (30), lumbar spine (28) and wrist/hand (27). Of the 60 respondents, 49 (82%) reported at least one; 17 (30%) sustained 2 separate MSDs and 18 (30%) sustained 3 or more MSDs. Of those who reported at least one MSD, 29 respondents (59%) underwent treatment; the most common being injection (12/49, 25%), physical or occupational therapy (6/49, 12%) and surgery (6/49, 12%). There was a significant relationship between age and the prevalence of MSDs in the shoulder or rotator cuff region (r=0.38; p=0.002). Conclusion: In a cohort of 60 EOS surgeons, more than 80% have sustained at least 1 MSD they self-attributed to EOS surgery, with the most frequent conditions affecting the cervical and lumbar spine and 58% reported >1 condition. Six participants (10%) underwent surgical treatment for an MSD they directly attributed to EOS surgery.

BACKGROUND:During radiographic assessment of adolescent idiopathic scoliosis (AIS), upright images frequently capture the hip. The purpose of this study was to assess the prevalence of radiographic hip dysplasia on postero-anterior (PA) scoliosis radiographs, as defined as a lateral center edge angle (LCEA) ≤25 degrees. METHODS:All patients with upright PA scoliosis radiographs over a one-year study period at a single tertiary academic medical center (2020 to 2021) were included in the study. Radiographs containing the hip joints were annotated by 3 reviewers for left and right LCEA, and triradiate cartilage (TRC) status. Inter-rater reliability was determined among the 3 reviewers. RESULTS:Two hundred fifty patients {500 hips, 75.6% female, median age 14 [interquartile range (IQR)=3]} had PA scoliosis radiographs that captured the hip, which qualified for analysis. Seventy-four hips (14.8%) demonstrated evidence of dysplasia (LCEA ≤25 deg) in 55/250 patients (22%). The median LCEA was significantly lower in the dysplastic hip cohort (23.9 deg, IQR=4.8 deg), compared with those without dysplasia (33 deg IQR=7.3 deg; P =0.001). A higher percentage of dysplastic hip patients were female than male (72.7% vs. 27.3%). Patients with bilateral dysplasia had a similar LCEA ( 22.9 deg) [to those with unilateral dysplasia (22.9 deg left, 23.9 deg right, P =0.689)]. CONCLUSIONS:In a cohort of 250 AIS patients, 22% demonstrated evidence of hip dysplasia, as defined as an LCEA ≤2 degrees. The dysplastic patients were more likely to be female. Screening for hip symptomatology in AIS patients may be of benefit, considering the frequency of radiographic hip dysplasia in this population. LEVEL OF EVIDENCE:III. Type of Evidence: diagnostic.

Background: The STOP questionnaire was developed to document reasons for discontinuation of growth-friendly (GF) treatment in early onset scoliosis (EOS). This study investigated the incidence of parental request (PR) on the STOP questionnaire and compared clinical information and Early Onset Scoliosis 24-Item Questionnaire (EOSQ-24) scores of PR patients with those whose parents did not request discontinuation (non-parent request [NPR]). Materials and Methods: An international pediatric spine registry was queried for EOS patients with STOP questionnaires completed by their surgeon. Age at discontinuation, sex, and EOS etiology were recorded. GF device, number of surgical procedures, complications, STOP questionnaire reasons for discontinuation, and definitive treatment were recorded. EOSQ24 scores and clinical information in the PR cohort were compared with the NPR cohort. Results: Data for 1326 patients were analyzed. PR was listed on the STOP questionnaires of 46 (3.5%) patients, completed at a mean age of 12 years (SD, 3.2 years). There were no statistical differences in number of procedures or complications when comparing the PR cohort with the NPR cohort. PR patients more frequently had neuromuscular EOS (P =.002), more frequently were treated with magnetically controlled growing rods (33% vs 14%, P =.036), and more frequently were observed after GF discontinuation (P =.628). EOSQ-24 scores for the PR cohort were significantly lower in most domains except pain/discomfort. Conclusion: For 3.5% of the EOS patients, PR was listed on the STOP questionnaire. They frequently had neuromuscular EOS and frequently were treated with magnetically controlled growing rods. Additionally, these patients had statistically lower EOSQ-24 scores across most domains. [Orthopedics . 20XX;4X(X):XXX-XXX.]

Background: Intraoperative imaging is often used to aid pedicle screw placement during scoliosis operations. Higher rates of cancer and death have been observed in orthopaedic surgeons and radiation technologists, including a fourfold higher rate of breast cancer in female orthopaedic surgeons. The purpose of this study was to evaluate variability in intraoperative radiation during spinal fusions for both adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS).Methods: A retrospective review of posterior spinal fusion and segmental spinal instrumentation for scoliosis performed by pediatric orthopaedic surgeons from 2017 to 2019 at a single institution was performed. Inclusion criteria included: a diagnosis of AIS or NMS and patients between 8 and 18 years of age. Exclusion criteria included: revision surgery, use of intraoperative navigation, and patients younger than 10 at the time of scoliosis onset within the AIS cohort. Data collected included: preoperative curve, body mass index (BMI), number of levels fused, number of Ponte osteotomies, and fluoroscopy time. One-way analysis of variance tests, Bonferroni post hoc tests, independent t tests, and Pearson correlations were utilized with significance determined at the 95% confidence level (a = 0.05).Results: A total of 148 patients were included in the study. The average fluoroscopy time was 143 +/- 67 seconds. Patients with NMS had higher average fluoroscopy times (193 +/- 75 s) compared with patients with AIS (129 +/- 58 s, P < 0.001). In patients with AIS, fluoroscopy time correlated to the patient's preoperative curve (r = 0.182, P = 0.050). Patients with AIS with fewer than 12 levels fused had significantly less radiation exposure than those with 12 or more levels fused (P = 0.01). When controlling for the number of levels fused, patients with AIS with higher BMIs had significantly greater fluoroscopy times (P = 0.001). In patients with NMS, fluoroscopy time negatively correlated with BMI (r = -0.459, P = 0.009) and positively correlated with a preoperative curve (r = 0.475, P = 0.007).Conclusion: Fluoroscopy times vary greatly during adolescent spinal fusions for scoliosis. Longer fluoroscopy times are correlated with: NMS diagnosis, larger preoperative curve, BMI, and number of levels fused. Surgeons' knowledge of factors affecting fluoroscopy time will increase awareness and may be the first step in decreasing intraoperative radiation risks.

Introduction: Guidelines regarding postsurgical dental care have been common in adult total joint arthroplasty patients despite limited supporting evidence in the literature. There is anecdotal evidence that similar precautions are implemented frequently in postoperative pediatric orthopaedic patients without any published evidence to guide clinicians. Methods: A survey of the Active Members of the Pediatric Orthopaedic Society of North America (POSNA) was performed to assess the use of postsurgical guidelines regarding dental care (procedures and prophylaxis) in pediatric patients. A 20-question survey regarding this subject was developed with the input of, and approved by, the Evidence-Based Practice Committee of POSNA, and a link to participate was distributed to the Active Membership. Results: One hundred seventy-three POSNA Members opened the link to the survey. One hundred sixty-three respondents self-identified as Active, for a response rate of 19.8%. One hundred fifty-seven (96.3%) reported direct involvement in surgical and postsurgical care of pediatric orthopaedic patients. Sixty-two (39.4%) indicated use of a postoperative protocol regarding dental interventions. Forty percent of those indicating use of guidelines were uncertain of the specifics of the protocol(s) used at their institution. Eighty-five percent of those utilizing protocols felt that the use of guidelines was a valuable topic for investigation. Conclusions: These results demonstrate that many of the active Members of POSNA utilize postsurgical guidelines for dental care, particularly for those patients who have undergone spinal surgery with permanent implants. This is despite the fact that there is limited evidence to support their use in adult total joint patients and no literature regarding use of such guidelines in pediatric orthopaedic patients. Key Concepts: (1) There is limited and contradictory evidence that postsurgical dental guidelines are indicated in adult orthopaedic patients. (2) There is no published evidence supporting postsurgical dental guidelines in pediatric orthopaedic patients. (3) Almost 40% of active Pediatric Orthopaedic Society of North America Members responding to a survey appear to utilize postsurgical dental care guidelines in pediatric patients, particularly after spinal procedures utilizing implants. Level of Evidence: Level V

To investigate the adoption and sustained use of telehealth for managing early-onset scoliosis (EOS) during and after the COVID-19 pandemic. A 35-question anonymous survey was emailed to 191 physician members of an international pediatric spine research group. Ninety seven clinicians completed the survey (51

Distraction-based growing rods have been considered as an alternative surgical option for the operative treatment of EOS. TGR has been challenged by MCGR, which is reported to have the advantage of non-invasive lengthening with fewer planned returns to theatre. This study explores the radiographic outcomes, Unplanned Returns to the Operating Room (UPROR) and complication profile of both the procedures at the end of the planned growing rod treatment with either TGR or MCGR. We included all the EOS cases from the PSSG database that underwent either TGR or MCGR with spine-based proximal anchors, followed up to the time of graduation. Any crossover or hybrid procedures were excluded. 549 patients (409 TGR and 140 MCGR) were eligible for review. We measured the coronal curve magnitude, Kyphosis, T1–T12, T1–S1 and L1–S1 lengths at 4 time points (before and after the index surgery and before and after the definitive surgery). The TGR group were slightly younger at the time of the index procedure (7 years for TGR vs. 8.5 years for MCGR, p < 0.001). We noted an improvement in all radiological parameters after the growing rod implantation. The spinal lengths increased through the lengthening period, while the coronal curve magnitude and the kyphosis increased. The kyphosis normalized following the final fusion, the coronal curve magnitude reduced further with a further increase in spinal lengths. The final follow-up from the time of the index implantation to the definitive surgery was 5.1 years (IQR 3.8) in TGR and 3.5 years (IQR 1.65) in the MCGR groups. The total number of complications was fewer in the MCGR group. The overall risk of UPROR was lower in the MCGR group and implant breakage was less in the MCGR group by 4.7 times. This study confirms the equivalence of both the distraction-based growing rods systems from the radiological stand-point, during the lengthening phase and at the time of the definitive surgery. The TGR was more kyphogenic during the lengthening period. The complications and UPROR were fewer in the MCGR groups.

Background: The development of new growth-friendly techniques for treating early-onset scoliosis (EOS) has resulted in a rapidly changing landscape of available treatment strategies. There is no literature revealing how a surgeon's years in practice (YIP) is related to the EOS techniques they learned in fellowship and how their YIP influences their decision-making in selecting EOS constructs. The purpose of this study was to assess how a surgeon's fellowship training and their years in practice (YIP) might affect which treatments they use in practice as well as attempt to gain insight into their decision-making process for such treatments.Methods: A 25-question survey was electronically delivered to 144 surgeons who treat EOS, and 87 (60%) responded. Surgeons were divided into two groups: a younger group (YG) with 0-10 YIP and an older group (OG) with >10 YIP. Growth-friendly techniques queried included serial casting, traditional growing rods (TGR), Vertical Expandable Prosthetic Titanium Rib (VEPTR), non-VEPTR rib constructs, Magnetically Controlled Growing Rods (MCGR), and Shilla. A Chi-square analysis was used to determine differences between the YIP groups with regard to which techniques surgeons learned in fellowship and which techniques they use in practice.Results: One hundred percent (38/38) of the YG surgeons were fellowship-trained versus 87.8% (43/49) of the OG surgeons. More YG versus OG surgeons received fellowship training in serial casting (84.2% vs. 38.8%, p<0.001), TGR (94.7% vs. 63.3%, p<0.001), VEPTR (65.8% vs. 28.6, p<0.001), non-VEPTR rib constructs (55.3% vs. 16.3%, p<0.001), and MCGR (47.4% vs. 2%, p<0.001). OG surgeons were more likely to use TGR in the last 3 years, with 26% of YG versus 6% of OG surgeons never utilizing TGR and 5% of YG versus 31% of OG surgeons performing TGR cases > 10 times (p=.004). Regarding treatment preferences, more YG surgeons (84.2% vs. 39.6%, p<0.001) preferred to delay intervention until final fusion rather than use any growth-friendly techniques. Furthermore, YG surgeons see a limited need for growth-friendly constructs other than MCGR.Conclusions: YG surgeons were more likely to learn growth-friendly techniques in fellowship than OG surgeons, though in their practices, the groups use growth-friendly techniques at similar rates. Compared to OG surgeons, YG surgeons prefer performing definitive fusions over utilizing any growth-friendly surgical techniques.Key Concepts•The landscape of treatment options for early-onset scoliosis has changed significantly over the past few decades.•Aside from younger surgeons' proclivity to use magnetically controlled growing rods at higher rates than older surgeons, the two groups reported using other growth-friendly treatments at similar frequencies.•Younger surgeons were more likely than older surgeons to prefer waiting to perform a single definitive fusion rather than using a growth-friendly technique to treat early-onset scoliosis.

Background: The current procedural terminology (CPT) coding system is used in medical record maintenance and billing. CPT coding is a skill that residents should acquire through training. The purpose of this study was to assess concordance between attending and resident coding practices in pediatric orthopaedic surgery. Methods: Case log reports were collected from 14 residents on the pediatric orthopaedic surgery service over 2 yr, then compared to operating room billing records from three pediatric orthopaedic surgeons. CPT code concordance rates were generated between residents and attendings for individual cases. Results: Three attending surgeons performed 1,372 cases over the two years. To accommodate cases in which multiple residents participated, 38 cases were duplicated (1,410 total attending cases). There was no corresponding resident case entry for 31.3% of attending cases. Of the 968 cases logged by residents, a 78.2% concordance rate was observed. Residents who rotated on pediatric orthopaedics only as a post-graduate year (PGY) 3 during the study period exhibited 73.8% concordance rates, versus residents that rotated as both a PGY-3 and PGY-4 who exhibited 78.7% and those who rotated only as a PGY-4 who exhibited 82.0% (P<0.001). Closed reduction and percutaneous pinning of supracondylar humerus fractures had the highest concordance rate (93.5%) among ACGME-required minimum category cases. Conclusions: Residents and attendings demonstrate a relatively high CPT code concordance among pediatric orthopaedic surgeries. Concordance rates were significantly higher when reported by more experienced residents. Among minimum category cases, percutaneous pinning of supracondylar humeral fractures demonstrated the highest concordance rate. Level of Evidence: Level IV

INTRODUCTION:After discontinuation of growth-friendly (GF) surgery for early onset scoliosis, patients are termed graduates: they undergo a spinal fusion, are observed after final lengthening with GF implant maintenance, or are observed after GF implant removal. The purpose of this study was to compare the rates of and reasons for revision surgery in two cohorts of GF graduates: before or after 2 years of follow-up from graduation. METHODS:A pediatric spine registry was queried for patients who underwent GF spine surgery with a minimum of 2 years of follow-ups after graduation by clinical and/or radiographic evidence. Scoliosis etiology, graduation strategy, number of, and reasons for revision surgery were queried. RESULTS:There were 834 patients with a minimum of 2-year follow-up after graduation who were analyzed. There were 241 (29%) congenital, 271 (33%) neuromuscular, 168 (20%) syndromic, and 154 (18%) idiopathic. 803 (96%) had traditional growing rod/vertical expandable titanium rib as their GF construct and 31 (4%) had magnetically controlled growing rod. Five hundred ninety-six patients (71%) underwent spinal fusion at graduation, 208 (25%) had GF implants retained, and 30 (4%) had GF implants removed.In the entire cohort, there were 108/834 (13%) patients who underwent revision surgery. Of the revisions, 71/108 (66%) occurred as acute revisions (ARs) between 0 and 2 years from graduation (mean 0.6 y), and the most common AR indication was infection (26/71, 37%). The remaining 37/108 (34%) patients underwent delayed revision (DR) surgery >2 years (mean 3.8 y) from graduation, and the most common DR indication was implant issues (17/37, 46%).Graduation strategy affected revision rates. Of the 596 patients with spinal fusion as a graduation strategy, 98/596 (16%) underwent revision, compared with only 8/208 (4%) patients who had their GF implants retained, and 2/30 (7%) that had their GF implants removed ( P ≤ 0.001).A significantly higher percentage of the ARs had a spinal fusion as the graduation strategy (68/71, 96%) compared with 30/37 DRs, (81%, P = 0.015). In addition, the 71 patients who underwent AR undergo more revision surgeries (mean: 2, range: 1 to 7) than 37 patients who underwent DR (mean: 1, range: 1 to 2) ( P = 0.001). CONCLUSION:In this largest reported series of GF graduates to date, the overall risk of revision was 13%. Patients who undergo a revision at any time, as well as ARs in particular, are more likely to have a spinal fusion as their graduation strategy. Patients who underwent AR, on average, undergo more revision surgeries than patients who underwent DR. LEVEL OF EVIDENCE:Level III, comparative.

Background: Hexapod devices, colloquially referred to as frames, are powerful tools to correct lower extremity deformity. However, patients who undergo treatment with frames are followed closely to ensure that clinical and radiographic correction are satisfactory. Depending on the size of the state and the number of surgeons that offer frame treatment, patients may need to travel a long distance and frequently, to obtain care. We sought to characterize the number of clinical and surgical encounters, as well as the cumulative driving distance, for frame patients treated at a single academic health center. Methods: All patients treated with a hexapod frame for any etiology by three pediatric orthopaedic surgeons at a single children’s hospital over an 8-year period were investigated. Patients were queried for demographic data, number of non-surgical and surgical clinical encounters and number of days in the frame. Driving distance was calculated from the patients address to the academic health system address. Results: Thirteen patients qualified for inclusion (10 male, 3 female). Mean age at frame application was 14.6 years (range 4-31). Mean time in the frame was 150.5 days (range 90-207). Throughout the course of their frame treatment, patients had a mean of 16 non-surgical (range 5-26) encounters and a mean of 3 (range 2-6) surgical encounters. Mean one-way driving distance between the treating institution and the patient’s home was 77 miles (range 20-212 miles). When two way driving distance was multiplied by the total number of encounters for each patient, the mean distance driven was 2616 miles (range 862-7632 miles). Conclusion: In this cohort of patients with a lower extremity frame, there were on mean 16 non-surgical and 3 surgical encounters, with a mean driving distance during the treatment program of 2600 miles. When agreeing to undertake a hexapod-assisted program for lower extremity pathology, patients should be counseled about the temporal and financial nature of this strategy, so they are aware of the large commitment needed.